Abstract

This opinion article brings considerations about advantages and challenges with the use of telehealth in sexual and reproductive health services aiming family planning in the face of COVID-19 pandemic new scenario.

Key words
Telehealth; reproductive health services; COVID-19

Resumo

Este artigo de opinião traz algumas considerações sobre vantagens e desafios do uso da telessaúde em serviços de saúde sexual e reprodutiva focado no planejamento familiar diante do novo cenário da pandemia da COVID-19.

Palavras-chave
Telessaúde; Serviços de saúde reprodutiva; COVID-19

Introduction

Since March 2020, when the World Health Organization (WHO) declared COVID-19, disease caused by the new coronavirus (SARS - CoV2), as a pandemic, the global population needed to adapt to this new condition and started to adopt several changes in lifestyle. Overload in health services, as well as socioeconomic and behavioral readjustments turned out to be the new challenges that the contemporary society needed to face.¹1 Lurie N, Carr BG. The Role of Telehealth in the Medical Response to Disasters. JAMA Intern Med. 2018; 178 (6): 745-46.^,22 Portnoy J, Waller M, Elliott T. Telemedicine in the Era of COVID-19. J Allergy Clin Immunol Pract. 2020; 8 (5): 1489-91.

Among various preventive measures used to mitigate COVID-19 dissemination, including compulsory quarantine, lockdown and restriction to access to health services, the use of telehealth presents itself as an adequate care alternative, since it does not demand personal contact, which may decrease the pandemic impact. Although telehealth use had increased globally in the last years, the current pandemic moment came to make it a reality for several developing countries and many services had been able to confirm its effectiveness.¹1 Lurie N, Carr BG. The Role of Telehealth in the Medical Response to Disasters. JAMA Intern Med. 2018; 178 (6): 745-46.

2 Portnoy J, Waller M, Elliott T. Telemedicine in the Era of COVID-19. J Allergy Clin Immunol Pract. 2020; 8 (5): 1489-91.^-33 Villani A, Scalvenzi M, Fabbrocini G. Teledermatology: a useful tool to fight COVID-19. J Dermatolog Treat. 2020; 31 (4): 325.

World regarded organizations such as Centers for Disease Control and Prevention (CDC) and American College of Obstetrics and Gynecology (ACOG) reinforced the expanded use of the telehealth system in this pandemic context.⁴4 ACOG (American College of Obstetrics and Gynecology). Implementing Telehealth in Practice Committee Opinion Number 798. Published February 2020 [accessed June 1, 2020]. Disponível em: https://www.acog.org/clinical/clin-ical-guidance/committee-ionoinion/articles/2020/02/imple-menting-telehealthin-practice.
https://www.acog.org/clinical/clin-ical-... ^,55 Dosaj A, Thiyagarajan D, Ter Haa C, Cheng J, George J, Wheatley C, Ramanathan A. Rapid Implementation of Telehealth Services During the COVID-19 Pandemic. Telemed J E Health. [accessed August 1, 2020]. Disponível em: https://www.liebertpub.com/doi/pdf/10.1089/tmj.2020.0219
https://www.liebertpub.com/doi/pdf/10.10... Several studies have already demonstrating many advantages in the use of telehealth due to the possibility of its application by health professionals in risk groups, as well as extinguishing geographic barriers and reducing waiting time to access health services.²2 Portnoy J, Waller M, Elliott T. Telemedicine in the Era of COVID-19. J Allergy Clin Immunol Pract. 2020; 8 (5): 1489-91.^,66 Alami H, Gagnon MP, Wootton R, Fortin JP, Zanaboni P. Exploring factors associated with the uneven utilization of telemedicine in Norway: a mixed methods study. BMC Med Inform Decis Mak. 2017; 17 (1): 180.^,77 Senderowicz L, Higgins J. Reproductive Reproductive Autonomy Is Nonnegotiable, Even in the Time of COVID-19. Int Perspect Sex Reprod Health. 2020; 46: 147-51. Telehealth also works as an important tool for information exchange and better inter-professional collaboration, generating alternatives of continuous learning and improvement of professional skills.⁵5 Dosaj A, Thiyagarajan D, Ter Haa C, Cheng J, George J, Wheatley C, Ramanathan A. Rapid Implementation of Telehealth Services During the COVID-19 Pandemic. Telemed J E Health. [accessed August 1, 2020]. Disponível em: https://www.liebertpub.com/doi/pdf/10.1089/tmj.2020.0219
https://www.liebertpub.com/doi/pdf/10.10... Among various benefits the use of telehealth brings, a review study found high rates of satisfaction of uses, decreasing of anxiety in patients with virtual meetings and a lower number of lost consultations.⁸8 Odibo IN, Wendel PJ, Magann EF. Telemedicine in obstetrics. Clin Obstet Gynecol. 2013; 56: 422-33.

Although patients accept this way of healthcare, managers of health services need to be alert for some obstacles that may occur during the implementation of this new technological tool. Among these obstacles, it is observed that even in an emergency scenario, people tend to use telehealth services in the way they did before the pandemic, and search for treatment with the same professional they already know, not accepting to be treated by a new professional, which may hinder telehealth. The lack of knowledge related to the use of this technology as well as the access to it are also factors that may limit the process of telehealth implementation.²2 Portnoy J, Waller M, Elliott T. Telemedicine in the Era of COVID-19. J Allergy Clin Immunol Pract. 2020; 8 (5): 1489-91.

Another important aspect that must be considered during telehealth adoption regards the moment in which the telehealth services are being provided, as they can be executed in synchronous and asynchronous methods. The first one is on live streaming, with communication in two sides, in which healthcare providers and patients see and listen to each other. The asynchronous method is based in storage and forwarding of patient’s information (system user) and posterior visualization and review by health service professionals (providers).³3 Villani A, Scalvenzi M, Fabbrocini G. Teledermatology: a useful tool to fight COVID-19. J Dermatolog Treat. 2020; 31 (4): 325.

4 ACOG (American College of Obstetrics and Gynecology). Implementing Telehealth in Practice Committee Opinion Number 798. Published February 2020 [accessed June 1, 2020]. Disponível em: https://www.acog.org/clinical/clin-ical-guidance/committee-ionoinion/articles/2020/02/imple-menting-telehealthin-practice.
https://www.acog.org/clinical/clin-ical-... ^-55 Dosaj A, Thiyagarajan D, Ter Haa C, Cheng J, George J, Wheatley C, Ramanathan A. Rapid Implementation of Telehealth Services During the COVID-19 Pandemic. Telemed J E Health. [accessed August 1, 2020]. Disponível em: https://www.liebertpub.com/doi/pdf/10.1089/tmj.2020.0219
https://www.liebertpub.com/doi/pdf/10.10...

Due to the increasing use of telehealth systems, many studies have demonstrated the unwanted consequences of different telehealth projects.⁹9 Alami H, Gagnon MP, Fortin JP. Some Multidimensional Unintended Consequences of Telehealth Utilization: A Multi-Project Evaluation Synthesis. Int J Health Policy Manag. 2019; 8 (6): 337-52.

10 Barr N, Vania D, Randall G, Mulvale G. Impact of information and communication technology on interprofessional collaboration for chronic disease management: a systematic review. J Health Serv Res Policy. 2017; 22 (4): 250-257.

11 Bloomrosen M, Starren J, Lorenzi NM, Ash JS, Patel VL, Shortliffe EH. Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting. J Am Med Inform Assoc. 2011; 18 (1): 82-90.

12 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007; 14 (5): 542-9.^-1313 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13 (5): 547-56.

These unwanted consequences (UCs) would be the results that are not expected by managers that planned the implementation.⁹9 Alami H, Gagnon MP, Fortin JP. Some Multidimensional Unintended Consequences of Telehealth Utilization: A Multi-Project Evaluation Synthesis. Int J Health Policy Manag. 2019; 8 (6): 337-52. Examples of some of these negative consequences or side effects have been documented, as the increase of stress and anxiety with the use of the new technology, demanded by the training of health professionals, changes in workflow, besides the dependence of the technology itself.⁹9 Alami H, Gagnon MP, Fortin JP. Some Multidimensional Unintended Consequences of Telehealth Utilization: A Multi-Project Evaluation Synthesis. Int J Health Policy Manag. 2019; 8 (6): 337-52.

10 Barr N, Vania D, Randall G, Mulvale G. Impact of information and communication technology on interprofessional collaboration for chronic disease management: a systematic review. J Health Serv Res Policy. 2017; 22 (4): 250-257.

11 Bloomrosen M, Starren J, Lorenzi NM, Ash JS, Patel VL, Shortliffe EH. Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting. J Am Med Inform Assoc. 2011; 18 (1): 82-90.

12 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007; 14 (5): 542-9.^-1313 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13 (5): 547-56.

The telehealth initiative applied to sexual and reproductive health services, which are considered essential, occurred in a largely reasonable way and was encouraged by governments, health authorities and non-governmental organizations, once they couldn’t be interrupt during this emergency moment in public health.²2 Portnoy J, Waller M, Elliott T. Telemedicine in the Era of COVID-19. J Allergy Clin Immunol Pract. 2020; 8 (5): 1489-91.^,44 ACOG (American College of Obstetrics and Gynecology). Implementing Telehealth in Practice Committee Opinion Number 798. Published February 2020 [accessed June 1, 2020]. Disponível em: https://www.acog.org/clinical/clin-ical-guidance/committee-ionoinion/articles/2020/02/imple-menting-telehealthin-practice.
https://www.acog.org/clinical/clin-ical-... ^,-¹⁴14 Townsend JW, Ten Hoope-Bender P, Sheffield J; FIGO Contraception, Family Planning Committee. Int J Gynaecol Obstet. 2020; 150: 273-4.

We understand that any service related to reproductive health that uses electronic communication technologyto provide contraception services or counselling constitutes a safe option positive costeffectiveness.⁴4 ACOG (American College of Obstetrics and Gynecology). Implementing Telehealth in Practice Committee Opinion Number 798. Published February 2020 [accessed June 1, 2020]. Disponível em: https://www.acog.org/clinical/clin-ical-guidance/committee-ionoinion/articles/2020/02/imple-menting-telehealthin-practice.
https://www.acog.org/clinical/clin-ical-... ^,1414 Townsend JW, Ten Hoope-Bender P, Sheffield J; FIGO Contraception, Family Planning Committee. Int J Gynaecol Obstet. 2020; 150: 273-4.^,1515 Bateson DJ, Lohr PA, Norman WV, Moreau C, Gemzell-Danie lsso n K, Blume nthal PD, Hog gart L, Li HR, Aiken ARA, Black KI. The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries [Editorial] . BMJ Sex Reprod Health. 2020; 1-3.

Concomitant to the incentive to the use of telehealth in reproductive planning services, some medical associations started to adopt new recommendation based on scientific evidences in response to threats that the pandemic brought to women’s sexual and reproductive health and their family’s wellbeing. The postponing of surgical sterilization, the expanded off-label use of long-acting reversible contraceptives (LARC), such as Intra Uterine Devices (IUD) and implants, are some guidelines that have been orientating in a largely prudent way some reproductive and sexual health services.⁷7 Senderowicz L, Higgins J. Reproductive Reproductive Autonomy Is Nonnegotiable, Even in the Time of COVID-19. Int Perspect Sex Reprod Health. 2020; 46: 147-51.^,1616 Society of Obstetricians and Gynecologists of Canada. SOGC COVID-19 resources, 2020. [Accessed August 11, 2020]. Available from: https://sogc.org/en/content/COVID-19/COVID-19.aspx?COVIDResources=2.
https://sogc.org/en/content/COVID-19/COV...

17 Faculty of Sexual & Reproductive Healthcare (FSRH). Essential services in sexual and reproductive healthcare, 2020. [accessed August 12, 2020]. Available from: https://www.fsrh.org/fsrh-and-covid-19-resourcesand-information-for-srh/.
https://www.fsrh.org/fsrh-and-covid-19-r... ^-1818 FIGO Committee on Contraception and Family Planning statement on COVID-19 and pregnancy. 2020. [accessed May 19, 2020]. Disponível em: https://www.figo.org/covid-19-contraception-familyplanning.
https://www.figo.org/covid-19-contracept... We support the expansion of family planning postpartum services recommended by FIGO (International Federation of Gynecology and Obstetrics) through its Contraception and Family Planning Committee, emphasizing the supply of LARC methods.¹⁶16 Society of Obstetricians and Gynecologists of Canada. SOGC COVID-19 resources, 2020. [Accessed August 11, 2020]. Available from: https://sogc.org/en/content/COVID-19/COVID-19.aspx?COVIDResources=2.
https://sogc.org/en/content/COVID-19/COV...

17 Faculty of Sexual & Reproductive Healthcare (FSRH). Essential services in sexual and reproductive healthcare, 2020. [accessed August 12, 2020]. Available from: https://www.fsrh.org/fsrh-and-covid-19-resourcesand-information-for-srh/.
https://www.fsrh.org/fsrh-and-covid-19-r... ^-1818 FIGO Committee on Contraception and Family Planning statement on COVID-19 and pregnancy. 2020. [accessed May 19, 2020]. Disponível em: https://www.figo.org/covid-19-contraception-familyplanning.
https://www.figo.org/covid-19-contracept...

Innovations in several contraceptive practices were implemented in different situations. The United Kingdom Faculty of Sexual & Reproductive Healthcare and the Society of Obstetricians and Gynecologists of Canada preconize the remote prescription of progesterone pills, isolated or combined to estrogen, during the pandemics, for up to one year,¹⁵15 Bateson DJ, Lohr PA, Norman WV, Moreau C, Gemzell-Danie lsso n K, Blume nthal PD, Hog gart L, Li HR, Aiken ARA, Black KI. The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries [Editorial] . BMJ Sex Reprod Health. 2020; 1-3.

16 Society of Obstetricians and Gynecologists of Canada. SOGC COVID-19 resources, 2020. [Accessed August 11, 2020]. Available from: https://sogc.org/en/content/COVID-19/COVID-19.aspx?COVIDResources=2.
https://sogc.org/en/content/COVID-19/COV... ^-1717 Faculty of Sexual & Reproductive Healthcare (FSRH). Essential services in sexual and reproductive healthcare, 2020. [accessed August 12, 2020]. Available from: https://www.fsrh.org/fsrh-and-covid-19-resourcesand-information-for-srh/.
https://www.fsrh.org/fsrh-and-covid-19-r... besides recommending women who want injectable contraception to search for tutorial videos about DMPA auto injection (Depot Medroxyprogesterone).¹⁹19 Sully EA, Biddlecom A, Darroch JE, Riley T, Ashford LS, Lince-Deroche N, firestein L, Murro R. Adding It Up: Investing in Sexual and Reproductive Health, 2019, New York: Guttmacher Institute. [accessed July 12, 2020]. Available from: https://www.guttmacher.org/report/adding-it-up-investing-in-sexual-reproductive-health-2019.
https://www.guttmacher.org/report/adding... In California, USA, drive-through services for injectable contraceptives, as well as the supply of injectable contraceptives for self-administration directly in drugstores have been one of the offered services that deserve to be high-lighted.¹⁵15 Bateson DJ, Lohr PA, Norman WV, Moreau C, Gemzell-Danie lsso n K, Blume nthal PD, Hog gart L, Li HR, Aiken ARA, Black KI. The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries [Editorial] . BMJ Sex Reprod Health. 2020; 1-3. Countless visits for counselling and follow-up of the use of contraceptive methods have been globally executed by means of tele-support, where the health providers that work in region with scarce inputs such as many Brazilian cities, perform an approach aiming individual needs of each user, trying to use the available technological resources in an effective way.

Even in services in which the infrastructure of technology for telehealth is possible, there may be situations that requires personal assistance, and in these cases, the assurance of all procedures of sanitary safety should be observed. In this way, it is yet recommended the scheduling of consultations, organization of waiting rooms following all the social distancing procedures and the use of adequate equipment of personal protection.¹⁵15 Bateson DJ, Lohr PA, Norman WV, Moreau C, Gemzell-Danie lsso n K, Blume nthal PD, Hog gart L, Li HR, Aiken ARA, Black KI. The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries [Editorial] . BMJ Sex Reprod Health. 2020; 1-3.

In that perspective, we support the access to services of high quality reproductive planning which use telehealth and offer a broad variety of contraceptive methods, always respecting the autonomy, dignity and confidentiality principles of the user, which are independent of the pandemic context.⁷7 Senderowicz L, Higgins J. Reproductive Reproductive Autonomy Is Nonnegotiable, Even in the Time of COVID-19. Int Perspect Sex Reprod Health. 2020; 46: 147-51.^,1515 Bateson DJ, Lohr PA, Norman WV, Moreau C, Gemzell-Danie lsso n K, Blume nthal PD, Hog gart L, Li HR, Aiken ARA, Black KI. The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries [Editorial] . BMJ Sex Reprod Health. 2020; 1-3. Users of telehealth services capable of planning their reproductive future, who can have the option of prevent a unwanted gestation in a safe manner, deciding about when and how many children they want to have, choosing the timespan between the gestations, as well as the moment to limit their families in a safe and healthy manner, are confident and socially included users.

During the process of implementation and adoption of telehealth services in the reproductive planning care, besides respecting the user’s autonomy and dignity precepts, the health service need to plan issues related to funding, logistics and human resources. In addition, the engagement and satisfaction of the user, which are also important tools in the implementation process. A detailed understanding about legal and regulatory changes which rule the telehealth services, coexistence of predatory services and sustainability of these implemented services are challenges that still persist.¹1 Lurie N, Carr BG. The Role of Telehealth in the Medical Response to Disasters. JAMA Intern Med. 2018; 178 (6): 745-46.^,55 Dosaj A, Thiyagarajan D, Ter Haa C, Cheng J, George J, Wheatley C, Ramanathan A. Rapid Implementation of Telehealth Services During the COVID-19 Pandemic. Telemed J E Health. [accessed August 1, 2020]. Disponível em: https://www.liebertpub.com/doi/pdf/10.1089/tmj.2020.0219
https://www.liebertpub.com/doi/pdf/10.10... ^,99 Alami H, Gagnon MP, Fortin JP. Some Multidimensional Unintended Consequences of Telehealth Utilization: A Multi-Project Evaluation Synthesis. Int J Health Policy Manag. 2019; 8 (6): 337-52.

Finally, we highlight the relevance and necessity of further studies of research and assessment of telehealth services, considering circumstances and environments where the service is implemented, the complexity of its implementation process, and the manner the service is perceived by the community and its potential to engage users and providers in the process.⁹9 Alami H, Gagnon MP, Fortin JP. Some Multidimensional Unintended Consequences of Telehealth Utilization: A Multi-Project Evaluation Synthesis. Int J Health Policy Manag. 2019; 8 (6): 337-52.^,2020 Vassilev I, Rowsell A, Pope C, Kennedy A, O'Cathain A, Salisbury C, Rogers A. Assessing the implementability of telehealth interventions for self-management support: a realist review. Implement Sci. 2015; 10: 59.

In this way, we believe that the development, implementation and usage of telehealth services should not be limited to a merely technical process, in which only effects and expected benefits of the technology are evaluated. We highlight the importance of further studies that assess continuously the incorporation and management of telehealth services in sexual and reproductive healthcare. Continuous evaluations that consider interdependence of human, technological, economic, ethical and socio-cultural factors that may influence the implementation and use of telehealth services are relevant and must be thought beyond the COVID-19 pandemic.

References

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